Motorbike Ambulances and Rural Maternal Health
by Rebecca Crouch

The barriers to accessing rural healthcare in the developing world are well documented. The urban concentration of services and qualified health professionals leave many rural populations under-served with poor perceptions of healthcare quality, whilst long distances to facilities, the costs of seeking care and strong socio-cultural health practices act to dissuade utilisation of services that are extended to rural communities.

Less well-documented are the effects that rural transport provision could have
on health access and outcomes. Transport is an essential element of any health
system, referring patients to and from medical care, by the quickest means
available. Transport provides a continuum of care between homes and health
facilities, accident sites and hospitals and between different levels of health
service infrastructures. Deficiencies in transport capacity cause delays in
patients reaching healthcare. Delays in decisions to seek care, reaching care,
and receiving care can have profound effects on health outcomes, especially
the outcomes of pregnancy and child delivery.

Rural women face a number of health challenges when pregnant, in labour and
post-partum. Among these challenges, a woman’s access to, and consequent
use of, professional delivery and Emergency Obstetric Care (EMOC) services is
critical in shaping maternal and neo-natal mortality. The physical access
barriers of ‘too far to walk’ distances and lack of transport, are widely
associated with professional service under-utilisation vis-à-vis
home/community deliveries. Seeing little added value in facility-delivery as
emergencies cannot be promptly referred to EMOC, women put their lives in
greater risk and high maternal mortality rates among rural women are evident
across the developing world. Rural transport solutions therefore, play a direct
and decisive role in determining maternal and neo-natal survival.

Non-motorised means of transport play a vital role in rural patients’ accessing
care. In the event of an emergency however, such as an obstetric complication,
such vehicles are inadequate. Whilst non-motorised transport is typically more
available, accessible and affordable to rural people, their functions are limited
to non-emergency cases and they cannot be understood as a viable alternative
to motorised emergency-referral transport options.

Motorised transport for rural health services is widely viewed as the provision
of 4x4 vehicles, as used by NGOs, government services and donor
organisations. But 4x4s are costly; to procure, operate and maintain. Due to
these expenses such vehicles are few in number and rarely available,
accessible or affordable to rural patients in need of transportation. However,
other motorised transport options exist.

Dowa district in central Malawi has among the worst incidence of maternal
deaths in the country. The district hospital is some 96km from its furthest rural
clinic, yet until 2005 it offered the only full EMOC in the district that was freeto-
use. Limited transport within public services and communities meant long
delays were often experienced by women waiting for transport to refer them to
EMOC. These delays in reaching EMOC have frequently been associated with
high maternal mortality and low use of professional delivery and EMOC
services among rural women in the district.

In July 2005, the district health office (DHO) implemented a strategy to
compliment their already comprehensive safe motherhood programme.
Additional to family planning, antenatal care, prevention-of-mother-to-child transmission and community education on the importance of professional care,
Dowa DHO also implemented service agreements with mission hospitals for
free-to-patient delivery and EMOC services and incorporated ten eRanger
motorbike ambulances into their maternal health-service-portfolio. The
eRangers have been in operation for 28 months.

Stationed on-site at ten rural health facilities, with two trained, local drivers
per motorbike ambulance, free-to-use and designated for EMOC referrals, the
eRangers are therefore readily available, accessible and affordable to women
who need higher-level care. The presence of the motorbike ambulances at
rural health facilities, providing designated EMOC transport, has allowed these
barriers and delays to be minimalised and reduced the likelihood of fatalities.

Lack of readily available, accessible and affordable EMOC transport was
associated with previously low use of professional delivery services, the
majority of women opting to deliver within their communities. Since the
introduction of the eRangers, district-wide facility-deliveries have almost
doubled. Increases in the number of women coming for delivery are believed
to result from the presence of designated EMOC referral transport. The
provision of transport enables women to reach EMOC promptly and hence
encourages them to use facility delivery services.

Prior to the introduction of the eRangers, the base-location of 4x4 referral
transport at Dowa district hospital rather than on-site at rural health facilities
meant that delays were an unavoidable reality, especially for those facilities
furthest from the hospital. The provision of on-site referral transport at rural
facilities has significantly cut such delays. The presence of the motorbike
ambulances is a significant factor in improving referral time and consequent
maternal survival since 2005.

Causes of maternal deaths in Dowa are associated with low utilisation of RHFdelivery and EMOC services due to multiple access barriers. Delays caused by
distance and transport barriers are noted significant influences. By providing
on-site, free-to-use, designated EMOC referral transport at rural facilities, the
motorbike ambulances fill a critical gap in maternal services in the district and
are universally associated with maternal mortality reductions since 2005.
Whilst Dowa’s neighbouring districts’ maternal mortality rates continue to
increase, Dowa’s maternal mortality rate dropped by almost half in the first 12
months of EMOC referral transport provision. By the end of the second year,
maternal mortality rates had fallen further still.

Rural transport provision is an intrinsic part of a functioning health system that
serves rural populations as well as urban, close-to-service populations. In
Dowa district, Malawi, the incorporation of the cost-effective, cost-efficient
eRanger motorbike ambulances is proving most beneficial; more women are
coming for delivery at facilities knowing they can be referred promptly to
EMOC if needed and more women who do need EMOC are reaching care
without delay, with huge improvements in maternal mortality.

Transport is a critical element of comprehensive health services. Until a time
when full services can be extended to rural populations, it is imperative that
referral systems properly function if health indicators are to improve. Rural
transport is therefore vital.

This opinion piece was contributed by Rebecca Crouch
Contact: nyeleni_lolo [at] hotmail.com

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